Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Berlin Institute of Health Charite Berlin Germany

Berlin Institute of Health Germany

Cardiology and CIC IT1414 CHU de Rennes LTSI Université Rennes 1 INSERM 1099 Rennes France

Cardiovascular Division Brigham and Women's Hospital Harvard Medical School Boston MA USA

Department of Biomedical Sciences for Health University of Milan IRCCS Milan Italy

Department of Cardiology and Pneumology University Medicine Göttingen Germany

Department of Cardiology Heart Valve Clinic University of Liège Hospital GIGA Cardiovascular Sciences CHU Sart Tilman Liège Belgium

Department of Cardiology IRCCS Policlinico San Donato Milanese Milan Italy

Department of Cardiology National and Kapodistrian University of Athens Medical School; University Hospital Attikon Athens Greece

Department of Internal Medicine and Cardiology Charité Universitätsmedizin Berlin Campus Virchow Klinikum

Department of Internal Medicine and Cardiology German Heart Institute Berlin Germany

Department of Physiology and Amsterdam Cardiovascular Sciences Amsterdam University Medical Center The Netherlands

German Center for Cardiovascular Research Berlin Partner Site Germany

German Centre for Cardiovascular Research Partner Site Frankfurt Germany

Institute for Clinical and Experimental Medicine IKEM Prague Czech Republic

Institute for Experimental and Translational Cardiovascular Imaging University Hospital Frankfurt

Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht University Utrecht The Netherlands

Medical University Clinical Military Hospital Wroclaw Poland

National Heart Centre Singapore and Duke National University of Singapore

School of Medicine Cardiff University Cardiff UK

Section of Cardiology Department of Medicine Sahlgrenska University Hosptal Ostra Göteborg Sweden

Section of Preventive Medicine and Epidemiology and Cardiovascular Medicine Department of Medicine Boston University School of Medicine Boston MA USA

University Heart Centre University Hospital Zurich Switzerland

University Medical Centre Groningen The Netherlands

University Medical Centre Groningen University of Groningen Department of Cardiology Groningen the Netherlands

University of Belgrade School of Medicine Belgrade University Medical Center Serbia

University of Cyprus School of Medicine Nicosia Cyprus

Eur Heart J. 2021 Mar 31;42(13):1274. doi: 10.1093/eurheartj/ehaa1016. PubMed

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